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Pattisapu N, Huang DT, Porter G, Owhonda R, Charlton T, Gross C, Thordarson D, Metzger MF. Polymethylmethacrylate (PMMA) Augmentation Enhances the Mechanical Characteristics of Midfoot Beam Constructs in Charcot Neuroarthropathy Cadaver Model. Foot Ankle Int 2024; 45:648-655. [PMID: 38501724 DOI: 10.1177/10711007241237804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Even with the best conservative care, patients with Charcot neuroarthropathy (CN) of the foot and ankle often ulcerate, increasing their risk of infection, amputation, and death. Surgical fixation has been associated with risk of recurrent ulceration, potentially due to poor bone quality prone to recurrent deformity and ulceration. We propose midfoot beam reconstruction with PMMA augmentation as a novel means of improving fixation. METHODS A protocol was developed to create characteristic CN midfoot fragmentation both visually and fluoroscopically in each of 12 matched-pair cadaveric feet. Afterward, the pairs were divided into 2 groups: (1) midfoot beam fusion surgery alone, and (2) midfoot beam fusion surgery augmented with PMMA. A solid 7.0-mm beam was placed into the medial column and a solid 5.5-mm beam was placed across the lateral column. In the PMMA group, 8 to 10 mL of PMMA was inserted into the medial column. The hindfoot of each specimen was potted and the metatarsal heads were cyclically loaded for 1800 cycles, followed by load to failure while load and displacement were continually recorded. RESULTS One specimen in the beam alone group failed before reaching the 1800th cycle and was not included in the failure analysis. The midfoot beam only group demonstrated greater mean displacement during cycle testing compared with the PMMA group, P < .05. The maximum force (N), stiffness (N/mm), and toughness (Nmm) were all significantly greater in the group augmented with PMMA, P < .05. CONCLUSION In a CN cadaveric model, PMMA augmentation significantly decreased gapping during cyclic loading and nearly doubled the load to failure compared with midfoot beams alone. CLINICAL RELEVANCE The results of this biomechanical study demonstrate that augmentation of midfoot beams with PMMA increases the strength and stiffness of the fusion construct. This increased mechanical toughness may help reduce the risk of nonunion and infection in patients with neuropathic midfoot collapse.
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Affiliation(s)
- Naveen Pattisapu
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Dave T Huang
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Giselle Porter
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rebisi Owhonda
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Timothy Charlton
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Christopher Gross
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston SC, USA
| | - David Thordarson
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Melodie F Metzger
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Wang Y, Zhou C, Yin H, Song D. Comparison of cement-augmented pedicle screw and conventional pedicle screw for the treatment of lumbar degenerative patients with osteoporosis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1609-1617. [PMID: 38363348 DOI: 10.1007/s00590-024-03849-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE To compare the safety and clinical efficacy between using cement-augmented pedicle screws (CAPS) and conventional pedicle screws (CPS) for the treatment of lumbar degenerative patients with osteoporosis. Management of lumbar degenerative patients with osteoporosis undergoing spine surgery is challenging. The clinical efficacy and potential complications of the mid-term performance of the CAPS technique in the treatment of lumbar degenerative patients with osteoporosis remain to be evaluated. PATIENTS AND METHODS The data of 131 lumbar degenerative patients with osteoporosis who were treated with screw fixation from May 2016 to December 2019 were retrospectively analyzed in this study. The patients were divided into the following two groups according to the type of screw used: (I) the CAPS group (n = 85); and (II) the CPS group (n = 46). Relevant data were compared between two groups, including the demographics data, clinical results and complications. RESULTS The difference in the VAS, ODI and JOA scores at three and 6 months after the operation between the two groups was statistically significant (P < 0.05). At 12 months after surgery and the final follow-up, a significant difference in the fusion rate was found between the two groups (P < 0.05). Four cemented screws loosening were observed in the CAPS group (loosening rate 4/384, 1.04%) and 15 screws loosening were observed in the CPS group (loosening rate 15/214, 7.01%). In the CAPS group, a total of 384 augmented screws were used, and cement leakage was observed in 25 screws (25/384, 6.51%), but no obvious clinical symptoms or serious complications were observed. Adjacent vertebral fractures occurred in six patients in the CAPS group and one in the CPS group. CONCLUSIONS CAPS technique is an effective strategy for the treatment of lumbar degenerative patients with osteoporosis, with a higher fusion rate and lower screw loosening rate than CPS.
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Affiliation(s)
- Yazhou Wang
- Department of Orthopedics, Shanghai Songjiang District Central Hospital, Shanghai, China
- Department of Orthopedics, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Chenghao Zhou
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, 650 New Songjiang Road, Songjiang District, Shanghai, 200080, China
| | - Huabin Yin
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, 650 New Songjiang Road, Songjiang District, Shanghai, 200080, China
| | - Dianwen Song
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, 650 New Songjiang Road, Songjiang District, Shanghai, 200080, China.
- Department of Orthopedics, Shanghai General Hospital of Nanjing Medical University, Shanghai, China.
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Liang TZ, Zhu HP, Gao B, Peng Y, Gao WJ. Intracardiac, pulmonary cement embolism in a 67-year-old female after cement-augmented pedicle screw instrumentation: A case report and review of literature. World J Clin Cases 2021; 9:3120-3129. [PMID: 33969099 PMCID: PMC8080748 DOI: 10.12998/wjcc.v9.i13.3120] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/04/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We report a case of Intracardiac, pulmonary, and intravenous cement embolism after cement-augmented pedicle screw instrumentation in treating spondylolisthesis underlying osteoporotic bone, which was successfully managed by conservative treatment. We describe the treatment and outcome of the patient, hoping to shed light on the management of bone cement embolism.
CASE SUMMARY A 67-year-old female suffered from progressive low back pain and numbness in lower extremities for 30 years. She was diagnosed with L4 and L5 spondylolisthesis, spinal stenosis, and osteoporosis. The patient underwent spinal canal decompression, an interbody fusion of L4/5 and L5/S1, cement-augmented pedicle screw instrumentation in L4-L5 segments, and regular pedicle screw in S1 segments. Three days postoperatively, a sudden drop in oxygen saturation occurred. Computerized tomography scan confirmed Intracardiac, pulmonary, and intravenous embolism. The patient was treated conservatively by continuous low-flow oxygen inhalation, anti-coagulation, and antibiotic therapy for 1 mo and continued anticoagulation treatment for 6 mo. The patient showed no further symptoms in a 30-mo follow-up.
CONCLUSION Intracardiac, pulmonary cement embolism after cement-augmented pedicle screw instrumentation is extremely rare. Careful clinical and radiographic evaluation is required in multiple sites of bone cement embolism. Conservative treatment may be a primary consideration in scattered emboli without life-threatening conditions, but a clinical decision should be made on an individualized basis.
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Affiliation(s)
- Tong-Zhou Liang
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510289, Guangdong Province, China
| | - Hai-Peng Zhu
- Department of Orthopedics, Guangdong Women and Children Hospital, Guangzhou 511400, Guangdong Province, China
| | - Bo Gao
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510289, Guangdong Province, China
| | - Yan Peng
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510289, Guangdong Province, China
| | - Wen-Jie Gao
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510289, Guangdong Province, China
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Guo HZ, Guo DQ, Tang YC, Liang D, Zhang SC. Selective cement augmentation of cranial and caudal pedicle screws provides comparable stability to augmentation on all segments in the osteoporotic spine: a finite element analysis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1384. [PMID: 33313129 PMCID: PMC7723578 DOI: 10.21037/atm-20-2246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Cement-augmented pedicle screw instrumentation (CAPSI) has been proven to significantly increase the biomechanical stability in the osteoporotic lumbar spine. However, besides the merits, it is responsible for the inevitable cement leakage growing with more instrumented segments and volumes involved. This study aimed to compare the biomechanical performance of pedicle screws augmented on all segments with those augmented only on the cranial and caudal vertebrae selectively. Methods The finite element model of L3-S1 was modeled with the CT data of a healthy volunteer, the solid/fenestrated pedicle screws from micro-CT scans of physical screws, and bone cement from the CT scans of a postoperative patient with CAPSI. Three different augmented strategies for pedicle screws were taken into consideration: augmentation at each pedicle trajectory (Model A), selective augmentation at the cranial and caudal pedicle trajectories (Model B), and pedicle trajectories without augmentation (Model C). A total of six surgical models were constructed: Models A, B, and C were subdivided into double segmental fusion from L4 to S1 (Models A1, B1, and C1) and multi-segment fusion from L3 to S1 (Models A2, B2, and C2). The Range of motion (ROM), stress on the cage, and stress on the fixed segments were compared among the six models. Results The ROM at the fusion segments decreased in all instrumentation models. The ROMs of Model B and Model A are similar in each direction, while that of Model C is significantly larger. The differences in the ROMs between Model A and Model B were noted to be less than 0.1°. Compared with Models A1 and A2, the peak Von Mise stress on the cage-endplate interface and pedicle screws were slightly higher in Models B1 and B2. In contrast, the stress of Models C1 and C2 increased significantly. The compressive stress was concentrated in the screw head, the cranial and caudal screws, and rods. Conclusions The selective augmentation of pedicle screws is capable of providing reliable stability in short-segment posterior fixation (2- or 3-level). It could be a potential optimal procedure to minimize the associated complications of CAPSI.
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Affiliation(s)
- Hui-Zhi Guo
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dan-Qing Guo
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yong-Chao Tang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - De Liang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shun-Cong Zhang
- The First Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Guo HZ, Zhang SC, Guo DQ, Ma YH, Yuan K, Li YX, Peng JC, Li JL, Liang D, Tang YC. Influence of cement-augmented pedicle screws with different volumes of polymethylmethacrylate in osteoporotic lumbar vertebrae over the adjacent segments: a 3D finite element analysis. BMC Musculoskelet Disord 2020; 21:460. [PMID: 32660462 PMCID: PMC7359596 DOI: 10.1186/s12891-020-03498-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background Polymethylmethacrylate (PMMA) is commonly used for cement-augmented pedicle screw instrumentation (CAPSI) to improve the fixation stability and reduce the risk of screw loosening in the osteoporotic thoracolumbar spine. Biomechanical researches have shown that various dose of cement (1-3 ml) can be injected to enhance screw stability. To date, there have been no studies on the relationship between adjacent segment degeneration and the volume of PMMA. This study aimed to explore the influence of CAPSI with different volumes of PMMA in osteoporotic lumbar vertebrae over adjacent segments by using finite element analysis. Methods Seven different finite element models were reconstructed and simulated under different loading conditions, including (1) an intact model, (2) three single-level CAPSI models with different volumes of PMMA (1, 1.73, and 2.5 ml), and (3) three double-level CAPSI models with different volumes of PMMA (1, 1.73, and 2.5 ml). To improve the accuracy of the finite element analysis, the models of the injectable pedicle screw and bone cement were created by using a three-dimensional scanning machine and the CAPSI patient’s CT data, respectively. The range of motion (ROM), the stress of intervertebral discs, and the stress of facet in the adjacent segment were comparatively analyzed among the different models. Results The ROMs of the different segments were compared with experimental data, with good agreement under the different load conditions (21.3°, 13.55°, 13.99°, and 6.11° in flexion, extension, bending, and rotation at L3-S1 level, respectively). Compared with the intact model, the ROM, disc stresses, and facet stress in adjacent segments were found to be higher in the six operative models. Otherwise, with a larger volume of PMMA injected, the ROM, disc stresses, and facet stress slightly increased at the adjacent segment. However, the differences were insignificant with the biggest difference less than 3.8%. Conclusions CAPSI could increase the incidence of disk degeneration in the adjacent segment, while within a certain range, different volumes of PMMA provided an approximate impact over the adjacent segment degeneration.
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Affiliation(s)
- Hui-Zhi Guo
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510407, Guangdong, People's Republic of China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Shun-Cong Zhang
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510407, Guangdong, People's Republic of China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Dan-Qing Guo
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510407, Guangdong, People's Republic of China
| | - Yan-Huai Ma
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510407, Guangdong, People's Republic of China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Kai Yuan
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yong-Xian Li
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510407, Guangdong, People's Republic of China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Jian-Cheng Peng
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510407, Guangdong, People's Republic of China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Jing-Lan Li
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510407, Guangdong, People's Republic of China
| | - De Liang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yong-Chao Tang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.
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Xu C, Hou Q, Chu Y, Huang X, Yang W, Ma J, Wang Z. How to improve the safety of bicortical pedicle screw insertion in the thoracolumbar vertebrae: analysis base on three-dimensional CT reconstruction of patients in the prone position. BMC Musculoskelet Disord 2020; 21:444. [PMID: 32635944 PMCID: PMC7341646 DOI: 10.1186/s12891-020-03473-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 07/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Through the comparison of three-dimensional CT reconstruction between the supine position and the prone position, the relative position of thoracolumbar great vessels and vertebral body was studied, and the shortest safe distance between them was measured to improve the safety of bicortical pedicle screw insertion and reduce the risk of vascular injury. METHODS Forty adults were selected to participate the research. Three-dimensional reconstruction of thoracolumbar (T9-L3) CT was performed in the prone position and the supine position. The relative distance between the Aorta/Inferior Vena Cava (IVC) and vertebral body was obtained as AVD/VVD respectively. The relative angle of the Aorta/ IVC and the vertebral body was calculated as ∠AOY/∠VOY. Self-controlled experiments were carried out in the prone and the supine positions, and the data obtained were analyzed using SPSS 22.0 statistical software. RESULTS The AVD of the prone position and the supine position was the shortest at T12 (3.18 ± 0.68 mm), but the difference was not statistically significant. The aorta of the T9-L3 segment was shifted from the anterolateral to the anteromedial. The ∠AOY of the other groups differed significantly between the prone and supine positions in all vertebrae except T12 and L1 (P < 0.05), and the aorta in the prone position was more anteromedial than that of supine position. With regard to VVD/∠VOY, there was no significant difference between the prone and supine positions (P ≥ 0.05), and the minimum VVD of L3 segment is greater than 5.4 mm. The IVC has no obvious mobility and is fixed in the range of 20 ° ~ 30 ° near the midline. CONCLUSION When using bicortical anchoring of pedicle screws, it is safe to ensure that the protruding tips of the screw is less than 3 mm. Due to the mobility of the aorta in different postures and individual differences in anatomy, the prone position CT can help doctors to make better preoperative plans and decisions.
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Affiliation(s)
- Chao Xu
- Qingdao University Medical College, Qingdao, 266071, Shandong, China
| | - Qingxian Hou
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266555, Shandong, China
| | - Yanchen Chu
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266555, Shandong, China
| | - Xiuling Huang
- Clinical Labororatory, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wenjiu Yang
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266555, Shandong, China
| | - Jinglong Ma
- Qingdao University Medical College, Qingdao, 266071, Shandong, China
| | - Zhijie Wang
- Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266555, Shandong, China.
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Tang YC, Guo HZ, Guo DQ, Luo PJ, Li YX, Mo GY, Ma YH, Peng JC, Liang D, Zhang SC. Effect and potential risks of using multilevel cement-augmented pedicle screw fixation in osteoporotic spine with lumbar degenerative disease. BMC Musculoskelet Disord 2020; 21:274. [PMID: 32345282 PMCID: PMC7189525 DOI: 10.1186/s12891-020-03309-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/22/2020] [Indexed: 02/07/2023] Open
Abstract
Background The increase of augmented level and bone cement dose are accompanied by the rising incidence of cement leakage (CL) of cement-augmented pedicle screw instrumentation (CAPSI). But the effect and potential risks of the application of CAPSI to osteoporotic lumbar degenerative disease (LDD) have not been studied in the case of multilevel fixation. This study aimed to investigate the effectiveness and potential complications of using multilevel CAPSI for patients with osteoporotic LDD. Methods A total of 93 patients with multilevel LDD were divided into the CAPSI group (46 subjects) and the conventional pedicle screw (CPS) group (47 subjects), including 75 cases for three levels and 18 cases for four levels. Relevant data were compared between two groups, including baseline data, clinical results, and complications. Results In the CAPSI group, a total of 336 augmented screws was placed bilaterally. The CL was observed in 116 screws (34.52%). Three cemented screws (0.89%) were found loosened during the follow-up and the overall fusion rate was 93.47%. For perioperative complications, two patients (4.35%) experienced pulmonary cement embolism (PCE), one patient augmented vertebral fracture, and three patients (6.52%) wound infection. And in the CPS group, thirty-three screws (8.46%) suffered loosening in cranial and caudal vertebra with a fusion rate of 91.49%. The operation time and hospital stay of CAPSI group were longer than the CPS group, but CAPSI group has a lower screw loosening percentage (P<0. 05). And in terms of blood loss, perioperative complications, fusion rate, and VAS and ODI scores at the follow-up times, there were no significant differences between the two groups. Conclusions Patients with osteoporotic LDD underwent multilevel CPS fixation have a higher rate of screw loosening in the cranial and caudal vertebra. The application of cemented pedicle screws for multilevel LDD can achieve better stability and less screw loosening, but it also accompanied by longer operating time, higher incidence of CL, PCE and wound infections. Selective cement augmentation of cranial and caudal pedicle screws may be a worthy strategy to decrease the complications.
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Affiliation(s)
- Yong-Chao Tang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Hui-Zhi Guo
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Dan-Qing Guo
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Pei-Jie Luo
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Yong-Xian Li
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Guo-Ye Mo
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Yan-Huai Ma
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Jian-Cheng Peng
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - De Liang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Shun-Cong Zhang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China. .,The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China.
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